SH NCP 41

Asbestos Policy
Version: 3

Summary The Asbestos Policy sets out how Southern Health NHS Foundation
Trust will comply with all relevant Health and Safety legislation regarding
the management of Asbestos.

Keywords Asbestos, Health, Safety, CAR2012, Management

Target audience All Trust Staff

Date issued December 2019

Approved & Estate Services MOM Date of meeting:

Ratified by 16th December 2019

Next review date December 2022

Author Robert Franklin, Asbestos Manager

Executive Director Heather Mitchell, Director of Strategy & Infrastructure Transformation

Equality Impact Assessment (for policies only)

The Equality Impact Assessment has been completed. The assessment document is held centrally
and is available by contacting policies@southernhealth.nhs.uk

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 Version Control

Change Record

Date Author Version Page Reason for Change

23/12/2016 Keith Alexander 2 1-14 Review of Policy – minor amendments only. Review date
extended for further 3 years
03/07/2019 Robert Franklin 3 All Review of policy

Reviewers/contributors

Name Position Version Reviewed & Date

Robert Franklin Asbestos Manager 03/07/2019 V3

Alison Edmundson Compliance Assurance Manager 17/07/2012 V1
23/12/2006 V2
03/07/2019 V3
Ivor Watson Senior Estates Capital Projects Manager 17/07/2012 V1
03/07/2019 V3
Paul Johnson Head of Estate services 17/07/2012 V1
Teresa Lewis Infection Control Nurse 17/07/2012 V1
Louise Hartland LEAD 17/07/2012 V1
Sharon Gomez LEAD 17/07/2012 V1
David Batchelor Governance 17/07/2012 V1
Carole Moor Compliance Administration Manager 17/07/2012 V1
Tiffany Hallett Legal Team 17/07/2012 V1
Keith Tutt Support Systems Manager 17/07/2012 V1
03/07/2019 V3
Tracy England Senior Contracts and PFI/LIFT Manager 17/07/2012 V1
Annette Chalmers Compliance Group Attendee 17/07/2012 V1
Kim Pullen Health and Safety Manager 23/12/2016 V2
Karl Allen Capital and Maintenance Delivery Manager 17/07/2012 V1

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 Asbestos Policy
Information on a page

This page summarises the key information or key steps in a process to follow. This does not
negate the need to be aware of and to follow the further detail provided in the document.

This Asbestos Policy sets out how Southern Health NHS Foundation Trust (the Trust) will manage
the risk posed to staff and contractors by asbestos-containing materials and how we will comply
with all relevant Health and Safety legislation regarding asbestos.

It also details the responsibilities of the Trust and its employees, contractors and regular building
users. All procedures outlined below are mandatory for all parties involved.

In order to meet statutory requirements, Trust objectives, healthcare requirements and best
practice, the Trust will:

a) Comply with statutory requirements for management of asbestos in buildings

b) Comply with best practice taken from ACOP L127 (The management of asbestos
in non-domestic premises) & L143 (Work with materials containing asbestos) and
relevant updates when they are made available
c) Comply with best practice from healthcare guidance (e.g. HTMs)

This Policy requires the cooperation of all employees, all staff, building users and contractors who
also have responsibilities to ensure a safe and healthy working environment is maintained at all
times.

This policy is not applicable to social care supporting living services. Any concerns should be
raised with the relevant Housing Provider and the Locality Manager.

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 Contents
Section Title Page
1. Introduction 5

2. Who Does This Policy Apply to? 5

3. Duties and responsibilities 6

4. Main content 9
4.1 Work with Asbestos 10
4.2 Identification of Asbestos 10
4.3 Asbestos Waste 11
4.4 Emergency Procedures 11

5. Training requirements 11

6. Monitoring compliance 12

7. Document review 12

8. Associated Trust documents and supporting references 12

9. Definitions 12

Appendices
1. Emergency Procedure Following Damage to Known or 14
Suspected ACM
2. Procedure Following Discovery of Suspect Asbestos Material 15

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 Asbestos Policy
1. Introduction

Asbestos is a naturally occurring mineral fibre that was commonly used in building and
insulation products up until the 1990’s. Materials containing asbestos fibres can release
these into the air, usually when the asbestos-containing material (ACM) is disturbed.
Inhalation of airborne asbestos fibres leads to increased risk of lung cancer and other
illnesses.

This Asbestos Policy sets out how Southern Health NHS Foundation Trust (the Trust) will
manage the risk posed to staff and contractors by asbestos-containing materials and how we
will comply with all relevant Health and Safety legislation regarding asbestos.

It also details the responsibilities of the Trust and its employees, contractors and regular
building users. All procedures outlined below are mandatory for all parties involved.

In order to meet statutory requirements, Trust objectives, healthcare requirements and best
practice, the Trust will:

a) Comply with statutory requirements for management of asbestos in buildings

b) Comply with best practice taken from ACOP L127 (The management of
asbestos in non-domestic premises) & L143 (Work with materials containing
asbestos) and relevant updates when they are made available
c) Comply with best practice from healthcare guidance (e.g. HTMs)

This Policy requires the cooperation of all employees, all staff, building users and contractors
who also have responsibilities to ensure a safe and healthy working environment is
maintained at all times.

This policy is not applicable to social care supporting living services. Any concerns should be
raised with the relevant Housing Provider and the Locality Manager.

2. Who does this policy apply to?

The Trust recognises its duties under the Health and Safety at Work Act, 1974 and the
Control of Asbestos Regulations 2012 and is committed to the effective management of
asbestos containing materials.

The Trust recognises its responsibilities to contractors and others involved in building and
maintenance projects established through the Construction (Design and Management)
Regulations 2015 and its duties as the ‘Duty Holder’ of Trust owned buildings as defined by
Regulation 4 of the Control of Asbestos Regulations 2012.

This policy applies to ALL SHFT staff and contractors carrying out work on behalf of the trust.
Where Estates and FM Services are managed on our behalf by another organisation they will
abide by the same policy.

The statutory requirements addressed in this policy apply to all the Trust’s sites where there
is a risk to any employee, service user, or member of public. This also applies to Trust
activities on shared sites, where the Trust has a duty to ensure safe systems are in place.
The Trust’s duties also extend to people in the surrounding neighbourhood who might be
inadvertently exposed to risks due to the activities of the Trust.

The policy should be read in conjunction with the SHFT Asbestos Management Plan relevant
legislation and NHS guidance.

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 3. Duties and responsibilities

The management structure below shows the key roles and appointments for the effective
and safe management of Asbestos.

Chief Executive
(Duty Holder)

Director of
Finance and
Corporate
Services

Associate Director
of Estate Services

Asbestos
Authorising
Engineer

Service Leads or Asbestos Senior Estates IT Team

Site Managers Manager Capital Projects
Manager
(Deputy Asbestos
Manager)

Capital Projects
Team

3.1 Chief Executive

The Chief Executive has the overall responsibility for health, safety and welfare of staff and
others affected by the work activities of the Trust and for the effective implementation of
asbestos management policies and procedures.

3.2 Director of Finance and Corporate Services

The Chief Executive has nominated the Director of Information and performance to carry the
specific responsibility for the effective implementation of asbestos management policies and
procedures.

3.3 Associate Director of Estate Services

The Head of Estates Service has delegated responsibility for the operational implementation
and monitoring of asbestos management policies and procedures.

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 3.4 Senior Estates Capital Projects Manager
The Senior Estates Capital Projects Manager has delegated responsibilities for the
operational implementation and monitoring of asbestos management policies and
procedures.

3.5 Service Leads or Site Managers

Service leads or site managers shall:
a) Ensure that the Asbestos Coordinator is informed immediately when asbestos is
identified or suspected so that assessments can be made and the appropriate
action taker.
b) Ensure that their department implements any procedures deemed necessary by
the Asbestos Coordinator.
c) Ensure departmental staff, patients or visitors are not at risk of exposure to
hazardous asbestos materials.
d) Ensure any work likely to affect asbestos materials is carried out after
consultation with, and in agreement with, the Asbestos Coordinator.
e) Ensure new equipment or apparatus erected, installed, purchased or gifted on
behalf of the divisional/directorate is free of asbestos material.
f) Receive and be aware of asbestos in their area of influence and ensure others in
their control are aware of the location of the Asbestos Policy and the location of
asbestos containing materials.

3.6 Asbestos Manager

The nominated Asbestos Manager for the Trust is:
Name: Robert Franklin
Contact Number: 07730 416 690
Location: Estates and Facilities Management, Tom Rudd Unit, Moorgreen Hospital.
Helpdesk: 0300 300 36 36

The above named person should be available if any help is needed to understand this
document; if any asbestos information is required; if any works are planned which may affect
known or suspected asbestos containing materials (ACMs); or if accidental disturbance of
ACMs is suspected.

The Asbestos Manager will:

a) Compile and maintain a record (Asbestos Register) of all known or suspected
Asbestos Containing Materials (ACMs) within of all premises owned or controlled
by the Trust.
b) Ensure that an Asbestos Management Plan is kept up to date and reviewed on a
regular basis as in accordance with Regulation 4 of the Control of Asbestos
Regulations 2012.
c) Be responsible for actively working with Estates to maintain services that could
compromise the service provision, ensuring safe accesses to suspected areas
when needed.
d) Actively lead and advise on the removal of any ACM that could compromise
access to areas, plant and or equipment within any of the Trust buildings.
e) Ensure that prior to any project works (refurbishment, demolition, etc.) ensure a
project-specific asbestos risk assessment is carried out and take steps to mitigate
the risk posed by any potential asbestos present in areas affected by the planned
works.
f) Inform all contractors working within Trust premises of the nature and extend of
any known or suspected ACMs which may affect their work; where all asbestos
information is kept; the name and contact details of the nominated Asbestos
Coordinator and what to do should they suspect asbestos has been disturbed.
g) Oversee the removal of any high-risk asbestos items identified throughout Trust
premises and actively manage any remaining asbestos to ensure the continued,
safe running of all Trust premises.

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 h) Implement and regularly review suitable control measures to ensure that the risk
from ACMs is adequately managed.
i) Ensure that all relevant personnel will undertake initial Asbestos Awareness
training and then annual refresher training to ensure they are kept updated on
new developments in the management and control of asbestos to ensure
competent performance of their specific duties. Attendance will be recorded and
maintained ready for inspection if required.
j) Ensure all asbestos information is made available upon request.
k) Be actively involved in monitoring of any asbestos removal or consultancy works
completed by a third party (such as an asbestos consultant, laboratory, principle
contractor or a licensed contractor). Where records or documents are prepared or
maintained by a third party, this will be clearly stated, and centrally controlled by
the Trust.
l) Ensure that labelling is undertaken in non-public areas and/or areas where
labelling is deemed necessary to ensure the safety of building users. (Labelling to
be carried out at the Trust’s discretion).
m) Only used licensed asbestos removal contractors to carry out any works on
asbestos containing materials.

3.7 Deputy Asbestos Manager

The Deputy Asbestos Manager will fulfil the role of the Asbestos Manager in their absence

3.8 IA Asbestos
The Trust’s asbestos management policy and procedures will be subject to regular external
audits from an Independent Auditor (AI) to ensure compliance with all relevant statutes and
guidance.

3.9 Asbestos Consultants

Where external asbestos consultants are used the Trust shall ensure that they possess the
relevant UKAS accreditation for the work they are carrying out (i.e. air testing, sample
analysis or surveys & inspections) and that they possess the required experience and
expertise to complete the work to a satisfactory standard.

3.10 IT Team
The SHFT IT team will ensure that any projects they undertake will comply with this policy.

The Asbestos Manager should be consulted prior to any project that may disturb the fabric of
any building constructed prior to 1999 as there may be a requirement for additional
“Refurbishment & Demolition” surveys, depending on the scope of the project.

The IT team must ensure that any work carried out does not disturb any ACM and any staff
carrying out any work should ensure that they have read and signed the asbestos register for
the site.

Any documents relating to asbestos removal or remediation must be sent to the Asbestos
Manager so that the asbestos management database can be updated accordingly.

The Asbestos Manager should be informed if the project scope changes to ensure all areas
affected by the planned works are included in the assessment.

3.11 Projects Team

Any projects that affect the fabric of the building must have a ‘suitable & sufficient’ risk
assessment for ACMs prior to work starting on site.

In practice this will mean that the Asbestos Manager should be consulted prior to the start of
the project to ensure that any required project-specific ‘Refurbishment & Demolition’ surveys

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 can be carried out in advance of any work and any ACMs that might be disturbed by the work
are removed or remediated as required.

The projects team must ensure that any project work carried out does not disturb any ACM
and any staff carrying out any work should ensure that they have read and signed the
asbestos register for the site.

Any documents relating to asbestos removal or remediation must be sent to the Asbestos
Manager so that the asbestos management database can be updated accordingly.

The Asbestos Manager should be informed if the project scope changes to ensure all areas
affected by the planned works are included in the assessment.

3.13 All Employees

All Southern Health staff must:
a) Actively cooperate with the Trust in all matters of Health and Safety and
proactively identify potential hazards to the Trust that may affect themselves or
other building users.
b) Not carry out any work on ACMs without written authorisation from the Asbestos
Manager.
c) Refrain from any activities which may disturb known or suspected asbestos
containing materials or undertake any refurbishment or demolition works prior to
consultation with the Asbestos Coordinator.
d) Work together with the Trust to prevent the spread or exposure to asbestos.
e) To report any incidents of exposure to asbestos or risk of harm due to failing to
follow this policy onto the Trust’s incident reporting system (Ulysses)

3.14 Health and Safety

The Health and Safety representative for the Trust is:

Name: TBC Number: 0300 300 36 36

4. Main content

To achieve the policy objectives, the Trust will:

a) Provide all resources deemed necessary to manage the risk posed by

asbestos, including the appointment of an Asbestos Manager
b) Take reasonable steps to undertake an assessment of all its owned/controlled
buildings, (and work together with any other nominated Duty Holder(s) with
regard to asbestos),
c) Expect the cooperation of all employees, regular building users and contracted
third parties in undertaking this assessment.
d) Implement systematic surveys to find and record the location and condition of
known or suspected ACMs.
e) Undertake an assessment of the risk of all known or suspected ACMs within its
owned/controlled buildings, or co-operate with those undertaking such an
assessment where the building is shared, let or rented.
f) Hold all conclusions and findings of all asbestos assessments, all surveys
commissioned and all other relevant information in a central and accessible
location.
g) Undertake all necessary steps to ensure asbestos information is made available
to all parties who may be affected by the presence of ACMs.
h) Ensure, as far as reasonably practicable, that anyone who may come into
contact with known or suspected asbestos within any of its owned or controlled
premises is made aware of all current information held regarding asbestos

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 i) Undertake the development of an Asbestos Management Plan which will be
monitored, reviewed and revised regularly, and which will state what steps will
be taken to manage the risk from known or suspected ACMs.
j) Undertake regular training of relevant staff and inform third party contractors
where necessary
k) Develop, implement and monitor safe systems of work to protect the safety,
health and welfare of employees, building users and third party contractors.
l) Provide appropriate precautionary health screening for relevant staff who may
have come into contact with ACMs during the course of their work.

The Trust will ensure that an asbestos register is maintained for each premise, containing
identification of likely or known locations of asbestos, an assessment of risks, and the
approach to management of those risks. The surveys will be carried out in accordance with
legislation and relevant ACOPs. This will be reviewed annually, and updated information
added whenever changes occur, e.g. at building refurbishment.

The Trust will also maintain an Asbestos Management Plan detailing how residual risks from
identified ACMs are managed.

4.1 Work with asbestos

The Control of Asbestos Regulations 2012 categorises work involving asbestos into three
broad areas.

1) Work that must be carried out by HSE-licensed contractors

2) Non-licensed work
3) Notifiable non-licensed work

SHFT will use a LARC for ALL work with asbestos in order to ensure the work is carried out
safely and in accordance with CAR2012. It is the responsibility of the LARC to ensure that
any relevant notifications are made to the enforcing authority.

If the work involves very low risk ACMs, SHFT may allow non-licensed contractors or
maintenance staff to carry out work with asbestos, provided the staff have received the
relevant training for working with asbestos and an appropriate method statement and risk
assessment has been prepared in advance. Any work with asbestos must have written
authorisation from the Asbestos Manager.

4.2 Identification of Asbestos

The Asbestos Manager will ensure that asbestos surveys are carried out in accordance with
HSG264 “Asbestos: The survey Guide”. If using an external organisation then they must be
UKAS accredited

All asbestos survey data will be held centrally within the Trusts asbestos management
database which is currently the MICAD system

Any samples for analysis will be sent to a company that is UKAS accredited for the
identification of asbestos fibres

Any air testing will be carried out by a company that is UKAS accredited for asbestos air
sampling and analysis.

SHFT do not routinely label asbestos, however labels may be fixed to ACMs where it has
been requested or local circumstances dictate that it would be beneficial to aid identification.

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 4.3 Asbestos Waste

Any asbestos removed from a site must be done so in accordance with the hazardous waste
regulations and be accompanied by the relevant waste consignment note.

SHFT has provided a secure, lockable container for the temporary storage of asbestos waste
generated by surveys or inspections. This waste will be disposed of as required and WCN
retained.

4.4. Emergency Procedures

The following procedure should be followed whenever suspected ACMs are found during
maintenance or refurbishment works:

1) Stop work immediately.

2) Isolate the area, i.e. shut doors and windows etc.
3) Post warning notices and inform people in the immediate area and request that
everyone move away.
4) Make contact with the Estates Helpdesk and Asbestos Manager for guidance and
instruction.
5) Appropriate risk assessments and control procedures shall be agreed following
consultation with the Asbestos Coordinator and implemented to avoid exposure
of ACMs to building users.
6) Encapsulation, treatment or removal of the disturbed ACMs shall be carried out in
accordance with current legislation before areas are re-occupied.

In circumstances where a ‘site’ is under control of a Principal Contractor and ACMs are
discovered the procedures contained in the Health and Safety Plan should be followed and
the Project Manager and Planning Supervisor informed as soon as practical.

The following points should be noted:

1) Do not allow works to continue on any materials which are suspected of

containing asbestos
2) Do not attempt to take an unauthorised sample. Samples should only be taken
under the supervision of the Principal Estates Manager and Specialist Advisor

5. Training requirements

In accordance with regulation 10 of CAR2012 any worker liable to disturb asbestos while
performing their normal everyday work is required to receive adequate asbestos awareness
training

Every employer must ensure that adequate information, instruction and training is given to
those employees who are liable to be exposed to asbestos during the course of their work.

The Asbestos Manager will ensure that all relevant personnel will undertake initial training
and then annual refresher training to ensure they are kept updated on new developments in
the management and control of asbestos to ensure competent performance of their specific
duties. Attendance will be recorded and maintained ready for inspection if required.

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 6. Monitoring Compliance

Element to be Lead Tool Frequency Reporting

monitored arrangements
The Trusts Asbestos Regular Quarterly Trust Health and
asbestos Manager asbestos Safety Forum
management management
software group
meetings
The annual Asbestos Regular Quarterly Trust Health and
Asbestos Manager asbestos Safety Forum
Management Plan management
group
meetings
Annual Independent Asbestos HSE Audit Annual Trust Health and
Authoring Engineer Manager Checklist Safety Forum
Audit

7. Document review

The document will be reviewed every 3 years, or sooner if changes in legislation occur or
new best practice evidence becomes available.

8. Associated Trust documents

Trust Health and Safety policy

Supporting references

 Hazardous waste regulations

 Health and Safety at Work Act, 1974
 Control of Asbestos Regulations 2012 and all associated Approved Codes of Practice

9. Definitions

Term Definition
SHFT, ‘The Trust’ Southern Health NHS Foundation Trust
Duty Holder the duty holder is, as defined in the ACOP;

a) every person who has, by virtue of contract

or tenancy, an obligation of any extent in
relation to the maintenance or repair of non-
domestic premises or any means of access
thereto or egress therefrom;

Or:

b) in relation to any part of non-domestic

premises where there is no such contract or
tenancy, every person who has to any
extent, control of that part of those non-
domestic premises or any means of access
thereto or therefrom, and where there is
more than one duty holder, the relative
contribution to be made by each such

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 person in complying with the requirements
of the regulation will be determined by the
nature and extent of the maintenance and
repair obligation owed by that person.

Employee’s and Refers to all direct employees, agency staff, long term
‘regular building contracted suppliers and those employed by Trust
users’ Directorates.
‘contractors’ Refers to all parties who undertake work for the Trust
on a short term, limited contract basis. This would
include tradespersons brought in for a specific task or
time period, but not those who have an on-going supply
agreement with the Trust.

Control Limit The control limit for asbestos is 0.1 asbestos fibres per
cubic centimetre of air (0.1f/cm3). The control limit is
not a 'safe' level and exposure from work activities
involving asbestos must be reduced to as far below the
control limit as possible.
ACM Asbestos containing material
Asbestos A document that details how SHFT will reduce the risk
Management Plan from specific identified ACMs as far as reasonably
practicable
LARC Licenced asbestos removal contractor
ACOP Approved code of practice
CAR2012 Control of Asbestos regulations 2012
CDM Construction, Design & Management regulations
WCN Waste Consignment Note, as required by the
Hazardous Waste regulations

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 APPENDIX 1 EMERGENCY PROCEDURE FOLLOWING DAMAGE TO KNOWN
OR SUSPECTED ACM

Evacuate all staff, visitors and personnel from the immediate area

Secure the area to prohibit anyone re-entering - by physical controls (locking rooms if possible) or
putting people on sentry duty

Inform the site manager and request immediate assistance in securing the immediate vicinity and limiting the
escape/spread of asbestos

The site manager must then contact the SHFT Asbestos Management Surveyor, the Facilities
Management team and any other specialist advisor deemed necessary - to assist in managing the
accident scene and checking the site asbestos register

Depending on the severity of the incident (the potential release of asbestos fibres) - names
and contact details of all person in the immediate vicinity of the accident scene should be
collated

Your facilities management team (normally SHFT Estate Services) will assume overall control of the
incident and subsequent isolation and remedial work in conjunction with the SHFT Asbestos
Management Surveyor

The site management team must also complete the SHFT Accident report form and forward
a copy to the SHFT H&S Unit

Note: The SHFT Asbestos Management Surveyor will attend site at the earliest opportunity
to inspect the area and take samples or arrange reassurance air testing, if necessary.

EMERGENCY CONTACT TELEPHONE NUMBERS:

SHFT Estates Services Helpdesk: 0300 300 36 36

SHFT Asbestos Manager: 07730 416 690

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 APPENDIX 2 PROCEDURE FOLLOWING DISCOVERY OF
SUSPECT ASBESTOS MATERIAL

Restrict further access to the suspect material and control immediate vicinity if material damaged and
inform the school site manager (or senior manager in his/her absence) of the situation, location and
concerns

Does the material possibly contain asbestos?

The site manager will review the 'Asbestos Register' to determine whether asbestos is known to
be in the location

YES NO UNKNOWN

(Known asbestos present) (No asbestos present) (Cannot verify)

Appropriate management action to be No further action Arrange for material to be

taken in accordance with the 'Site-
Individual to be
specific Emergency Procedures
informed - and details
entered onto Asbestos
Register
inspected and sample tested
where necessary (SHFT Asbestos
Management Surveyor can assist).
Once result known, follow the
relevant procedures in this flow
chart

EMERGENCY CONTACT TELEPHONE NUMBERS:

SHFT Estates Services Helpdesk: 0300 300 36 36

SHFT Asbestos Manager: 07730 416 690

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